SCHEDA MEDICA

Dati generali:

Cognome: _____________________________________ Nome: _________________________________________

Nato a: _____________________________________ Il _____________________________________________
Abitante a: _____________________________________ Via: __________________________________ n______
Tel.: ____________ / ___________________

Gruppo sanguigno: _______________ RH: _________________

Vaccinazioni effettuate:

Antipolio data ___________

Antidifterica data ___________
Antivaiolosa data ___________
Antipertossica data ___________
Antiepatite B data ___________
Altre: ________________ data ___________
________________ data ___________
Antitetanica: data ultimo richiamo ___________

Malattie infettive avute in passato:

1) _______________________________ 6) _______________________________
2) _______________________________ 7) _______________________________
3) _______________________________ 8) _______________________________
4) _______________________________ 9) _______________________________
5) _______________________________ 10) _______________________________

Intolleranze a cibi particolari:

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Allergie:
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Difetti congeniti:
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Altro:
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Nome e numero di telefono del medico di famiglia:

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N.B.:
? allegare la fotocopia del tesserino sanitario (meglio se fotocopiato sul retro di questa scheda)
? se esistono particolari medicine da somministrare nel caso di allergie o difetti congeniti scriverlo in fianco alle rispettive voci
nella scheda.

Se siete sicuri di averci detto tutto quanto riguarda vostro figlio, firmate qui __________________________________________

Date di revisioni e aggiornamenti:

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